A new report has been published today by the British Psychological Society Division of Clinical Psychology entitled ‘Understanding psychosis and schizophrenia: why people sometimes hear voices, believe things that others find strange, or appear out of touch with reality, and what can help’.

The report is being formally launched at a conference today in London.

The 180-page document has been written by a “working party mainly comprised of clinical psychologists drawn from the NHS and universities”. It has been welcomed by a number of key mental health organisations, including Mind.

This blog offers a critique of three key elements within the report, each of which has been tackled by an individual with special interest in the area:

The working party who put together the report (over a period of 2 years) is made up of 25 people, the majority of whom are clinical psychologists. The introduction tells us that more than a quarter of the contributors are people with lived experience, i.e. “people who have themselves heard voices, experienced paranoia or received diagnoses such as psychosis or schizophrenia”. The report is edited by Anne Cooke.

It is unclear from the report what specific methodology was used to put the document together. As far as we can tell, no methods are described for literature searching, inclusion criteria, assessment of studies, critical appraisal etc. We would welcome a response from the team who produced the report to clarify this important issue.

The Division of Clinical Psychology “promotes the professional interests of Clinical Psychologists across the UK”.

1. CBT for psychosis: Keith Laws

Meta-analyses

Understanding Psychosis & Schizophrenia (UPS) includes a section entitled ‘Talking – Psychological Help’, which refers broadly to talking therapies, but focusses on Cognitive Behavioural Therapy (CBT) as the jewel-in-the-crown of talk therapy- given that other talk therapies remain largely un-evidenced for schizophrenia and psychosis. The report begins by attempting to establish the ‘scientific’ credibility of CBT, highlighting findings from several meta-analyses of – what are now – over 50 published Randomised Controlled Trials (RCTs). The authors state that:

Although they each yield slightly different estimates, there is general consensus that on average, people gain around as much benefit from CBT as they do from taking psychiatric medication.19, 20, 21, 22, 23, 24, 25, 26

The extraordinary claims in this sentence deserve closer scrutiny. The only real consensus is that the average effect size of CBT for psychosis has been unremittingly shrinking; now down to 0.15 for total symptoms (this is averaged across 5 recent large meta-analyses). In plain language 94% of those receiving CBT will overlap in symptom outcome with controls who receive only treatment as usual; and for clinicians to attain one more favourable outcome from CBT (compared to controls), therapists would need to treat almost 22 people. CBT for psychosis is an intervention that is not statistically significant, not clinically significant and therefore not cost-effective.

Although those CBT advocates conducting RCTs have almost exclusively used CBT as a quasi-neuroleptic i.e. focussing on whether CBT reduces the symptoms of psychosis, UPS talks much more about ‘distress’ and reducing distress. While ‘distress reduction’ is a laudable target for therapists, the very few trials that have measured ‘distress’ as an outcome provide no support for CBT being efficacious in this regard either.

But potentially the most dangerous and fallacious claim is that:

people gain around as much benefit from CBT as they do from taking psychiatric medication

In this context, the authors cite a selection of CBT meta-analyses (refs 19 to 26; including Jauhar et al 2014 twice [21 & 25], where I am a co-author). However, none of the cited work compares effect sizes for CBT and medication and for one good reason: not one RCT has ever compared the efficacy of CBT and antipsychotic medication. It is disconcerting that a document endorsed by the British Psychological Society so boldly misrepresents the findings and misinforms patients, with potentially serious implications for decisions that they make regarding their health care.

National Institute of Clinical Excellence (NICE)

The UPS authors repeatedly refer to the guidance from NICE on CBT, for example, stating that:

[NICE] considers the evidence strong enough to recommend that everyone with a diagnosis of schizophrenia should be offered CBT

Despite such appeals to authority (and the UPS authorship contains current and past members of the NICE committee advising on CBT for psychosis, including the Chair), the current NICE recommendations are based on possibly the least reliable meta-analysis ever published on this topic. Strictly speaking, it is not a meta-analysis but a trawl of ‘110 meta analyses’ that fail to directly assess study quality and only examine RCTs up until 2008. Since 2008, at least 14 better quality RCTs have been published and only one reports a significant effect of CBT on psychosis symptoms (and that was a non-blind study). In a remarkable critique (Perera & Taylor 2014) of the recent NICE (CG178) 2014 update (sic), the Chair of the SIGN committee (the Scottish version of NICE) Professor Mark Taylor says:

…it is unfortunate that the guideline appears at times to reflect the interests of its authors rather than impartial up-to-date evidence

Schizophrenia Commission and the ‘One-in-ten’ claim

Finally, the UPS document repeatedly refers to a recent report by the Schizophrenia Commission, when they reiterate the claim that the SC:

…found that only one in ten people who could benefit from it have access to good CBTp 30. We view this with grave concern – indeed, it has been described as scandalous31

A 10% figure would be scandalous (as so-described in a blog by some UPS co-authors); however, UPS surprisingly fails to elaborate at all on this figure, which is so dramatic that we ought to look closer. A glance at the SC report reveals that the 10% claim comes from a presentation to the Schizophrenia Commission by ‘Haddock’; and more astonishingly perhaps, the SC also give no further detail). The unreliability of this 10% figure is a case study in how myths emerge in mental health when we consider data on CBT for psychosis provision in the recent National Audit of Schizophrenia covering all 64 NHS trusts in England and Wales.

The NAS found that:

CBT was offered to 39% of service users, with a range of 14% to 67% across Trusts

A mean figure almost 4 times larger than quoted in UPS. Interestingly, of those offered CBT, NAS also report that more than half decline this talk therapy. When ‘service-users’ across all Trusts in England and Wales themselves were asked, the majority said they had either been offered or had declined CBT for psychosis, leaving a minority (46%) who “had not received CBT and had not indicated that they did not want to receive it”) – which, of course, is not the same as this minority saying that they do want CBT.

Here at the Mental Elf, we will continue searching for the evidence to support CBT for psychosis.

2. Medication: Alex Langford

The medication section of Understanding Psychosis and Schizophrenia leaves me with mixed feelings.

The benefits of antipsychotic medication

There are certainly some positive aspects. Most importantly, the report notes that medication can be helpful for some people, even sometimes on a long-term basis. A series of poignant vignettes are given to illustrate those facts. This is a welcome message, because medication can sometimes feel like a dirty word when in conversation with psychologists less supportive of the medical model.

The lengthy discussion about making sure that medication decisions are collaborative, informed and focussed on making sure the patient takes as little as they need is surely something we can all agree on. Additionally, the space dedicated to side effects is probably justified in being very comprehensive.

Little evidence for the dopamine hypothesis?

However, despite the scattered strong points, the space dedicated to medication reads very much as a step-by-step critique of it. For example, more than half of the free text in the ‘how medication can be helpful’ segment is spent undermining how medications are commonly thought to work – with highly scientifically controversial statements.

The ‘key point’ that there is ‘little evidence that [medications correct] an underlying abnormality’ is bizarrely unfounded. An excellent summary by Kapur & Howes (referenced earlier in the report itself) and further imaging studies by Howes and others provide solid evidence for elevated presynaptic dopamine levels being a key abnormality in psychosis, and there is copious evidence that inhibiting the action of this excess dopamine using antipsychotics leads to clinical improvement in psychosis.

Psychiatrists adopting a ‘drug-centred’ approach?

Another assertion that ‘some psychiatrists are suggesting adopting a ‘drug-centred’ rather than a ‘disease-centred’ approach’, whereby medications are thought of merely as tranquillisers not as specific agents to treat specific symptoms, also completely fails to match my experience of clinical reality. On not one ward, in not one clinic, in not one discussion with another psychiatrist, have I come across that ethos. The only place I’ve seen it is in critical psychiatrist Joanna Moncrieff’s book The Myth of the Chemical Cure, which is referenced three times in the medication section, (as is her personal blog and a scientific paper by her) but let’s just say her theories aren’t widely accepted.

Underemphasising the benefits of antipsychotic medication

As well as their underlying mechanisms of action, the benefits of medication seemed to be grossly underemphasised. The report spares only a few vague sentences on their advantages, but the commonly used antipsychotics have effect sizes of around 0.4 to 0.66, which is huge. Clozapine, the one antipsychotic which is more effective than all the others, has an effect size for symptom reduction of 0.88 – immense. As for preventing relapses, on average only 2 to 3 patients need to take an antipsychotic for one of them to avoid a relapse; a number the rest of medicine is envious of and which no other invention for psychosis comes close to.

None of this is to say that drugs should be the only treatment we offer – no psychiatrist believes that – but misrepresenting the facts isn’t very helpful for the people being offered the tablets. Of note, I didn’t see any psychiatrists named as contributors to the report, but I’m happy to be corrected.

A note on ‘terminology’

I was also interested in the constant use of inverted commas around ‘antipsychotic’, and indeed the sporadic use of ‘psychosis’ itself in the same state. Clearly the authors, and those who they feel they represent, choose to see the terms not as ‘real’ but as ‘constructed’ or ‘disputed’. I’m fine with that – but I wonder if it will serve the interests of the majority of people for whom this report is meant. For those who have come to form their narrative of suffering and healing using these terms, which is plenty, I can see the inverted commas being quite devaluing. Again, I’m happy to be challenged.

Justifying forced medication

One final sticking point for me was the short section, found later in the report, on ‘whether forced medication can ever be justified’. The report chose only to mention that although ‘some’ psychologists agree that detention can be justified, forced medication is becoming less justifiable, and a UN Special Rapporteur on torture has compiled a report against it. This is selective information in the extreme.

The report might have better informed its readers by stating that both detention and the giving of medication against the wishes of a patient is sadly commonplace, but also something that is widely accepted as necessary, occurring across the whole of medicine when patients are too unwell to make decisions for themselves. They could have mentioned that two legal frameworks (the Mental Capacity Act 2005 and the Mental Health Act 1983) support this practice, and given details of both, including how patients could seek help if they become involved in such a process. The relevance of the UN Special Rapporteur report, a dense and esoteric document which was compiled after visits to a collection of developing countries and bears relatively little consequence to current UK practice, should have been explained. Including it as the sole legal reference in this section seems tendentious.

A 2012 Cochrane systematic review found that, on average only 2 to 3 patients need to take an antipsychotic for one of them to avoid a relapse. However, it also concluded that this effect must be weighed up against the side effects of antipsychotic drugs.

3. The psychological and biomedical models: Samei Huda

Psychological and biomedical models are complementary

Understanding Psychosis and Schizophrenia (UPS) aims to outline the psychological model of psychosis. It does a reasonable job of this whilst failing to recognise the limitations of this model. It is also less successful when discussing aspects of the biomedical model which the authors don’t understand very well, despite their apparent belief that they do.

Of course both models illuminate important aspects of the psychosis phenomenon. UPS talks about the continuum of human experience that overlaps with psychosis. This is important to recognise whilst also pointing out that many medical disorders exist on continua with “normality” (e.g. high blood pressure, type II diabetes etc). It’s important to state that many people who hear voices don’t have mental illness. In clinical practice, I do use the continuum model with people I see who don’t have a serious mental illness.

Explaining psychosis

The biomedical model often doesn’t explain why these events occur (except in cases where clear aetiology exists such as illegal substances or delirium) apart from stating they are phenomenon as part of a disorder. The biomedical model often doesn’t explain the content of delusions or hallucinations well. The psychological model explains this aspect of content better. People tend to be more interested in the content of their experiences or thoughts than the form they take.

Where a psychological model is less successful is in explaining why these unusual experiences take the particular form they do in individual people. Why do different patients have PTSD or depression or anxiety or voices or delusions or OCD (or different combinations of these) in response to trauma? The biomedical model doesn’t help here either, just using the explanation of underlying unseen disorder, but it doesn’t claim to make everything understandable and explicable, as the psychological model does. Incorporating “constitutional” factors turns the psychological “understanding” model into a biopsychosocial medical model.

In terms of explaining the kind of delusions I see in people with schizophrenia, the psychological model is better at explaining some of the factors that maintain the belief, but less about why they formed that particular belief. It doesn’t explain the change in perception of reality that the delusion flows from. Even the example formulation of the bizarre delusion doesn’t explain why the bizarre belief was formed and accepted. The psychological model presented here doesn’t explain the experiences of thought insertion, withdrawal and broadcasting. Discussion of ego boundary disintegration might have been useful. There is a lack of convincing explanation of First Rank Symptoms.

Psychosis is more than just delusions and hallucinations

The reduction of psychosis to just hallucinations and delusions is flawed. To be fair, this can be blamed on DSM III onwards. Cognitive impairment is attributed to distraction and arousal, and negative symptoms to depression and arousal also. Whilst this may be true in some people, this doesn’t explain the wide range of cognitive impairments seen in many people with schizophrenia (and to a lesser degree in their first degree relatives) not caused by medication and why there are group differences with people with bipolar disorder. Some negative symptoms appear to be primary, not caused by depression or secondary to self-disorders as assessed by the EASE interview (see www.EASEnet.dk for details). Cognitive impairment and negative symptoms are important as they often have a bigger effect on social functioning than hallucinations or delusions.

Thought disorder is described as being caused by being flustered thus temporarily disorganised in speech. This trivialises and doesn’t explain the persistent thought disorder I see in some people.

The UPS report would have been stronger if it acknowledged it’s weaknesses, but this goes against its absolutist view that all psychosis phenomenon can be understood. It states Bentall’s view that once psychosis can be understood then there is no reason to posit an underlying illness. Hence any weaknesses in understanding are skated over, and phenomena not easily explained in this way are minimised.

Failure to acknowledge limitations of the model

It’s unclear why the authors felt the need to discuss medication given their lack of expertise. Some of the recommendations are unrealistic. In many cases where people have psychotic experiences that cause them to be at risk to themselves or others, their views should be respected but they should still have help in acknowledging an illness viewpoint so they can make good treatment choices. In some cases, in order to reduce imminent risk to themselves and others, compulsory treatment is necessary, though the threshold should be high.

In short, useful in parts, but undermined by the authors unwillingness to admit limitations of their model.

Nine ostriches and not a grain of sand in sight. We’d love to here your views about this new report. Please post your comments below.

Summary

Our thanks to Keith Laws, Alex Langford and Samei Huda for working to such a tight deadline in putting this blog together. We hope that you find their critique interesting and useful.

We are keen to hear your views of the Understanding PsychosisandSchizophrenia report. What does it add to our existing knowledge? How will it impact on patient care? What changes (if any) should be made to mental health services as a result? Please comment in the thread below to let us know what you think.

Keith Laws is Professor of Cognitive Neuropsychology in the School of Life and Medical Sciences at the University of Hertfordshire. He completed a PhD at the Department of Experimental Psychology, University of Cambridge and is the author of over 100 papers and a recent book entitled 'Category-Specificity: Evidence for Modularity of Mind'. He is a Chartered Psychologist, an Associate Fellow of the British Psychological Society, a Fellow of the Royal Society of Arts, a Member of the Institute of Learning and Teaching and various academic organisations including the British Neuropsychological Society, British Neuropsychiatric Association, and the Experimental Psychology Society.

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Dr Samei Huda has been working as a Consultant Psychiatrist for over 12 years including a year in Australia. He also completed a Diploma in Cognitive Therapy (though he doesn’t see patients for therapy) and a Master of Science in Psychiatry. He has been working with an Early Intervention in Psychosis team since 2007. Over his career he has directly assessed, managed and treated hundreds of patients with psychosis of different types. He recommends people with an interest in psychosis to read www.EASEnet.dk (he is not affiliated with them).

Vaughan Bell brilliantly exposed the moral shortcomings and intellectual shallowness of “Understanding Psychosis and Schizophrenia” In http://mindhacks.com/2016/04/05/critical-mental-health-has-a-brain-problem/ using his clinical experience as a psychologist working to improve the life of fellow human beings suffering from neurological disorders. I cite from a short text well worth of reading in full:
“(…)These critical approaches suggest that common mental health problems are best understood in terms of life history and meaning but those that occur alongside neurological disorders are irrelevant to these concerns.
Ironically, this line of reasoning implies that people without clearly diagnosable neurological problems can’t be reduced to their biology, but people with these difficulties clearly can be, to the point where they are excluded from any arguments about the nature of mental health.(…)The British Psychological Society’s report Understanding Psychosis simply doesn’t discuss anyone who might have psychosis associated with brain injury, epilepsy, dementia or any other alteration to the brain as if they don’t exist – despite the fact we know these neurological changes can be a clear causal factor in developing psychotic experiences. In fact, dementia is likely to be the single biggest cause of psychosis.
In a recent critical mental health manifesto, the first statement is “Mental health problems are fundamentally social and psychological issues”.(…)
All mental health problems are important. Why segregate people on the basis of their brain state?(…)
Mental health problems in people with neurological diagnoses are just as personally meaningful.
Social and psychological approaches can be just as valuable.
If your approach to ‘destigmatising’ mental health problems involves an attempt to distance one set of people from another, I want no part of it.(…)”

Great and (as far as I can tell) very fair critique. There’s a disappointing disconnect between clinical psychologists (as a profession) and psychiatrists in the UK that seems to be more interested in supporting ideological positions rather than on evidence-based care and research. I don’t remember this being the case at all in Australia.

This is a superb and a thorough takedown of the 200 pages or so, of a shamelessly retro book put out by British Psychological Society for its Division of Clinical Psychology. One of the shameful actions of the BPS is that many of the authors of this book are identified as “service users.” But there was no procedure for sampling adequate range of service user opinion. I’m confident that many, perhaps most service uses would not identify with the voice is being given to them. This is not just a matter of just a methodology, but of ethics. I highly recommend this blog post, but don’t recommend the book unless you’re drunk and stoned, like some of the psychologists who contributed to might have been.

The paragraph on forced psychiatry is naive. The convention on the rights of people with disabilities CRPD has been ratified by UK. It brings into question the medical model bias of existing mh law, insisting on a social model. It renders almost all ctos and sectioningand other forced approaches as what they are, crimes against humanity. It forces services to start thinking differently and clealy judging by that paragraph some people are going to suffer a lot of pain and heartache with regards adjusting their approach to madness.

There’s many good criticisms you could make of the BPS Understanding Psychosis document but I’m not sure this is quite as good as it could be. Keith’s section is a solid critique. However, I think things get a little more dicey from there. Alex, you defend the point that ‘medications correct an underlying abnormality in psychosis’. The first thing to note is that the imaging study you link to is not on people with psychosis (it’s on a UHR group, who actually show no difference at all from controls in presynaptic dopamine turnover in the limbic striatum [really, see Table 3] – as the dopamine theory of psychosis would predict, plus weak stats etc etc). However, this is clearly just a bit of an oversight as several PET studies have found elevated presynaptic dopamine levels in patients with acute (but not chronic) psychosis but typically with a large overlap between patients and controls. In other words, lots of people without acute psychosis show higher levels of presynaptic dopamine turnover than those with acute psychosis, or, alternatively, many people with psychosis show entirely normal levels of the same.

This is in line with lots of the relevant literature. For example, clozapine, which you rightly note is the most efficacious for schizophrenia, has one of the lowest d2 receptor occupancy profiles, patients for whom antipsychotic do not work show no difference in antipsychotic d2 receptor occupancy, and also do not show elevated presynaptic dopamine. What the wider evidence suggests is that dopamine dysregulation is an important risk factor present in many patients but is not a necessary component for all cases of psychosis and neither does ‘correcting’ this always help, so the final common pathway remains a theory, but not one that accounts for all psychoses. Understanding Psychosis overplays the ‘no consistent biology’ angle but suggesting that the ‘dopamine hypothesis’ is an answer is as much of a caricature. The truth is likely to be complex with multiple pathways to psychosis, many of which the report discusses quite ably.

You mention that you have not come across the ‘drug centred’ approach to psychiatric medication but this is markedly common to the point where it is widely promoted by industry, evidence and prescribing guidelines. For example, ‘antipsychotics’ are currently licensed and / or evidenced for schizophrenia, mood stabilisation, control of agitation, treatment of depression, augmentation of SSRI treatment and so on. This evidence of wide efficacy applies to pretty much any psychiatric established medication or class of medication. To suggest that the mechanism of antipsychotics is specific to reversing the pathology of psychosis (Moncrieff’s ‘disease-centred’ approach) is simply counter the evidence for the wider efficacy of these drugs. The drug-centred approach is really just a plain description of modern psychiatric evidence. Medications have neurochemical effects which may be more or less specific to the causal pathways of different difficulties but are more widely used for their general effects. This is, in great part, the story of much modern medicine.

“Underemphasising the benefits of antipsychotic medication” – totally agreed with you here to balance the discussion of potential adverse effects. “Justifying forced medication” – I agree what you say about the out-of-context discussion of UN Special Rapporteur report, but the section in Understanding Psychosis seems to be making an ethical argument. It would be better, as you mention, to admit that forced medication could be given equally under the Mental Capacity Act regardless of having a diagnosis of psychosis, but the report argues for decisions on coercion to be made on this basis (rather than under the Mental Health Act, George Schmukler’s position and closer to the Scottish model). Should medication never be given forcibly? I’m sure there are some situations where this might always be necessary, but should we work towards a system where this is a rarity rather than a commonality, I hope we can all agree that we can.

The psychological and biomedical models section. Sam, I’m a massive fan of your stuff, but I’m afraid I don’t think this is a good critique. Actually, your main point that ‘Psychological and biomedical models are complementary’ and that the report ‘doesn’t sufficiently acknowledge limitations of the model’ are sound and important and I wish more people would pay attention to this. However, good critiques are best made with reference to the relevant evidence and I see very little of it here except mentioning things it doesn’t account for. A model doesn’t have to be complete to be useful, it has to be well-supported and useful. There are various psychological models (not just one, something that isn’t clear enough in the report) and most fulfil both of these criteria. Psychological models are important, biological models too. They are, as you say, complementary.

Folks, if I could make a wider point. According to the blog post, this was put together in a short space of time and largely focused on negative things in the report. I’m not sure how helpful rushing out a critique that spent so little time on the report’s positive contributions really is. Yes, it doesn’t deal with the evidence in therapy and neurobiology as well as it should, but when I read it, I was struck by how inclusive it was and how it tried to build bridges between medical and psychological approaches to psychosis. There is a lot to be commended here.

The field of mental health suffers from poor investment in services, a still basic understanding of causes and, finally, and unfortunately, a culture of divisiveness. I say this as someone who has a doctorate in clinical psychology and a PhD in neuropsychiatry – both of these approaches are important and we should work towards unity in approach, debate and community, with people who need assistance leading the way, with those who can help at their sides.

The recent Lancet Psychiatryeditorial is as good a manifesto as you can get for this, and I hope we’re equally as much for what we can admire in other people experiences, work and approaches, as for what we can critique and improve.

[…] fair to say that some responses to this report have shown that old battle lines and divisions still run deep within the mental health professions. I want to add my own thoughts to this discussion at some point but not today for a couple of […]

[…] sick of it. Why? Because the instant it was published, so were psychiatric critiques, most notably this one from the Mental Elf. Just as last May psychologists jumped all over the DSM-5, psychiatrists were poised to take on the […]

As webmaster of a schizophrenia site for 11 years I doubt psychologists is the solution of schizophrenia, as one of the most ill mmembers of 2500 had a mother who was a psychologist.

In Sweden we can check if psychologists have fewer or less ill children with schizofrenia. It would be so if they are right.

The most important role for the psychologist is to discuss in the ward after the first psyhosis about delusions and voices. After that we have to wait for the stronger CBT with effect on psychosis, which todays CBT lacks (if it has any effect at all).

Bit dissapointed that they did not note that there could be similarities between schizophrenia, anxiety and depression. There is a comorbity, bur also similarities in symptoms – anxiety = delusion, negative thoughts in depression = negative voices in schizophrenia.

As a technically trained medical layman, I hope I will be forgiven a somewhat irritated observation. Many of those here seem to be arguing over how many angels can sit on the head of a pin! The evidence base for BOTH medication and therapy appears to me to be very weak in patients with severe distress, delusions, voices, sharp mood swings, etc. Side effects of anti-psychotic drugs are major, including addiction, non-trivial tardive diskinesia, damage to intellect, and permanent numbing of emotional affect. Some have called these meds “chemical lobotomy” with a good deal of justice.

The evidence for less severe issues like depression and anxiety seems a bit clearer: medications do no more than placebo and often harm the patient, up to and including suicide.

I wonder if you folks wouldn’t actually learn something by handing over your whole mess plus a couple of Billion dollars to a bunch of otherwise uninvolved engineers or ops research folks (like me) and asking us to design a unified large scale trial (NOT a meta analysis!). Take a year and a thousand practitioners, to compare patient outcomes of the three medications most often prescribed for psychosis versus CBT, Open Dialog, and another talking therapy of your choice. Publish your protocols widely for critique and refine them before beginning trials.

[…] Understanding Psychosis and Schizophrenia: a Critique by Laws, Langford and HudaThe Psychological Elf Weblog publishes criticisms of the report that target: the proof for CBT for psychosis; using treatment in treating psychosis; and the restrictions of a purely psychological mannequin of the situation. Additionally take a look at Vaughan Bell’s response within the feedback, and this blog post from Henry Strick. […]

Keith laws meta analysis has only 1/3rd of it’s sample reaching nice criteria for effective cbtp the other 2/3 rds of the studies in the paper he is coauthor of are shorter CBT groups and 3 Chinese studies peters (2014) reply to the paper

Just read intro to report and am already fuming. Had a brother who suffered from schizophrenia who regularly refused treatment and was dead at 41, have a relative who first had symptoms at 13, now in her twenties and stable on clozapine, but nearly died from suicide s on the way to getting a diagnosis and treatment. Time spent looking for non-existent traumatic events is time wasted…….

I can think of no worse disrespect to the authors of Understanding Psychosis than the haste and superficiality of thought driving this largely shallow critique. If this website wanted to have a dialogue that improved the quality of care provided to users of mental health services, this was certainly no way to get there.
Understanding Psychosis is a fine compilation of resources and valuable analysis for building and supporting the health, agency and options for service users/patients, their families, and the professionals who provide mental health services. At its center is the primacy of patient/service user agency, respect, and health.
Unlike your critique, Understanding Psychosis provides readers with tools that serve more than symptom alleviation, an important, but rather low, standard. We are more than symptoms—and the solutions on offer frequently cause horrific, life-threatening problems (mentioned only in passing here). Often referred to with that minimizing term—“side effects”—these all-too-common results of pharmaceutical intervention (tongue thrusting and jaw-gurning, mounting anxiety and akathesia, the deadened sex drive, massive weight gain, somnolence, and iatrogenic sickness) too often occupy the center of a life.
Your commentators’ remarks are disappointing in a number of ways—for both potential users of Understanding Psychosis, and because they fall far short of your vaunted scientific objectivity and high evidentiary standards. (We would all have been put right from the beginning if they’d simply written: “We don’t have any idea about most of the material in this compilation, so don’t expect more than a glancing mention of anything except the things that offend us.”)
The question that immediately springs to mind is: Who and what was served by posting this incomplete, opinion-riddled, and error-challenged critique? As Bell notes, Langford, for example, ‘mischaracterises’ a study (oops–wrong population!) that is the foundation of his criticism. He then spends a chunk of time on his opinion about the drug-centered approach—which must be wrong, you see, because it doesn’t match his experience. (And then, to defend himself on both counts, uses a version of “Well, it *was* er, incomplete–but I had to have something so I could pile on with the other boys!”) This, Mental Elf, represents your high evidentiary standards?
Law’s criticisms of the CBT research seem to be the only one of significance; I imagine they will be useful to the authors. Note, of course, that the CBT section is a very small part of this work.
Point-scoring (and I am, of course, echoing some of @BipolarBlogger’s post on this topic) was the purpose of this critique, and only that. There was little (if any) interest in being of help to service users, other mental health professionals, and certainly not the Understanding Psychosis authors.
If that desire had been paramount, this site, for example, would also have engaged the participation of a reviewer in an allied health field to comment on the document, and certainly one or more service users. At the very least, you would have fact-checked the post.
(It has been both alarming and instructive to see the big, jostling crowd that has come to join in on this assault; it has become a veritable circle-jerk, complete with gleeful howls and crowing. When the Mental Elf, based on comments in his Twitter timeline, attempted to procure Eleanor Langdon’s contact information to draw her into this mess, I could not help but wonder why he would expect her to come and lie down in this bed he’d made. That would be crazy.)
Full disclosure: I follow and have exchanged social media messages and information with the editor and several of the Understanding Psychosis contributors. I particularly hold Jacqui Dillon, Anne Cooke, and Rufus May in high regard.

[Edit 1/12/14 08:05am: the final sentence of this comment has been removed as it contains a potentially defamatory allegation].

I’m a believer in the content and approach written of in the Understanding Psychosis report because I’ve never believed in the biomedical model of mental illness since a 17 year old girl seeing my mother in a locked psychiatric ward. My mother experienced altered mind states due to life stressors and didn’t deserve the forced ECT then the lifelong depixol injection until her death at age 68 in 1998.

I didn’t believe it when they tried to pin the label on me in 2002 and managed to break free. However in my family some of us do accept the mental illness label and that the psychiatric drug treatment is helpful. They find the support of mental health professionals positive, even if the treatment wasn’t always gentle or kind. I feel differently but try to respect their viewpoint.

What bothered me about this report was that I don’t think it will “convert the unbelievers”, those who are firmly behind biological psychiatry, who think it’s genetic rather than generational, in the brain rather than in the mind. I think it has the potential to cause greater division and entrenchment. Polarised opinions as a psychiatrist colleague described it. Them and us. The “in crowd” and those outside the circle.

So in a sense I’m critical of the report yet a believer in the content. Divided. Yet rather than being divided I want to see a broad church in psychiatry and room for a variety of beliefs without us all coming to blows over our differences. Let the survivors speak out and the service users have their say. I was a runner from psychiatry while others ran to psychiatry. Force can’t be the answer to differences of opinion. In my opinion.

Many thanks to the authors of this very clearly written and useful critique. Though many of us who are family caregivers for people living with schizophrenia know that the authors of “Understanding Psychosis” certainly don’t understand what our family members are living with, we lack the research skills necessary to refute the astonishing assertions found in this document. Keith Laws, Alex Langford and Samei Huda’s blog is providing a great service. It’s disturbing to see how quickly the new document is being spread in Canada and many of us are very grateful to be able to link to the well-informed perspectives provided by The Mental Elf’s blog.

[…] With this in mind, the importance placed on FRS may potentially reflect an out-dated historical bias. It is also perhaps worth mentioning that there is a general bias towards ‘positive’ symptoms as a whole (hallucinations and delusions), when cognitive impairment and ‘negative’ symptoms (e.g. flattened affect) have been found to have a bigger impact on social functioning over time. […]

[…] sick of it. Why? Because the instant it was published, so were psychiatric critiques, most notably this one from the Mental Elf (although it should be noted one of the authors of this particular document is a psychologist). […]

[…] first edition of this report was covered in a Mental Elf blog in 2014 (Understanding Psychosis and Schizophrenia: a critique by Laws, Langford and Huda), which focused on the sections on medication, CBT and the medical model (Understanding Psychosis […]

[…] first edition of this report was covered in a Mental Elf blog in 2014 (Understanding Psychosis and Schizophrenia: a critique by Laws, Langford and Huda), which focused on the sections on medication, CBT and the medical model (Understanding Psychosis […]